Provider Demographics
NPI:1619131414
Name:JACKSON, ELENA PATRICIA (PT)
Entity Type:Individual
Prefix:MRS
First Name:ELENA
Middle Name:PATRICIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 ANGELIQUE CT
Mailing Address - Street 2:
Mailing Address - City:LANOKA HARBOR
Mailing Address - State:NJ
Mailing Address - Zip Code:08734-2231
Mailing Address - Country:US
Mailing Address - Phone:609-971-5348
Mailing Address - Fax:609-971-0827
Practice Address - Street 1:703 ANGELIQUE CT
Practice Address - Street 2:
Practice Address - City:LANOKA HARBOR
Practice Address - State:NJ
Practice Address - Zip Code:08734-2231
Practice Address - Country:US
Practice Address - Phone:609-971-5348
Practice Address - Fax:609-971-0827
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-11
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00951400172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker